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Identification of patients who are at a high risk for right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is of critical importance. Conventional tools for predicting RVF, including two-dimensional echocardiography, right heart catheterization (RHC), and clinical parameters, generally have limited sensitivity and specificity. We retrospectively examined the ability of computed tomography (CT) ventricular volume measures to identify patients who experienced RVF after LVAD implantation. Between September 2017 and November 2021, 92 patients underwent LVAD surgery at our institution. Preoperative CT-derived ventricular volumes were obtained in 20 patients. Patients who underwent CT evaluation had a similar demographics and rate of RVF after LVAD as patients who did not undergo cardiac CT imaging. In the study cohort, seven of 20 (35%) patients experienced RVF (2 unplanned biventricular assist device, 5 prolonged inotropic support). Computed tomography-derived right ventricular end-diastolic and end-systolic volume indices were the strongest predictors of RVF compared with demographic, echocardiographic, and RHC data with areas under the receiver operating curve of 0.79 and 0.76, respectively. Computed tomography volumetric assessment of RV size can be performed in patients evaluated for LVAD treatment. RV measures of size provide a promising means of pre-LVAD assessment for postoperative RV failure.

Management of chronic thromboembolic pulmonary hypertension (CTEPH) should be determined by a multidisciplinary team, ideally at a specialized CTEPH referral center. Radiologists contribute to this multidisciplinary process by helping to confirm the diagnosis of CTEPH and delineating the extent of disease, both of which help determine a treatment decision. Preoperative assessment of CTEPH usually employs multiple imaging modalities, including ventilation-perfusion (V/Q) scanning, echocardiography, CT pulmonary angiography (CTPA), and right heart catheterization with pulmonary angiography. Accurate diagnosis or exclusion of CTEPH at imaging is imperative, as this remains the only form of pulmonary hypertension that is curative with surgery. Unfortunately, CTEPH is often misdiagnosed at CTPA, which can be due to technical factors, patient-related factors, radiologist-related factors, as well as a host of disease mimics including acute pulmonary embolism, in situ thrombus, vasculitis, pulmonary artery sarcoma, and fibrosing mediastinitis. Although V/Q scanning is thought to be substantially more sensitive for CTEPH compared with CTPA, this is likely due to lack of recognition of CTEPH findings rather than a modality limitation. Preoperative evaluation for pulmonary thromboendarterectomy (PTE) includes assessment of technical operability and surgical risk stratification. While the definitive therapy for CTEPH is PTE, other minimally invasive or noninvasive therapies also lead to clinical improvements including greater survival. Complications of PTE that can be identified at postoperative imaging include infection, reperfusion edema or injury, pulmonary hemorrhage, pericardial effusion or hemopericardium, and rethrombosis.

A 7-day course of glecaprevir/pibrentasvir started in the preoperative period prevented transmission of hepatitis C virus (HCV) from viremic donors to 10 HCV-negative recipients (2 heart, 1 lung, 6 kidney, 1 heart/kidney) with 100% sustained virological response at 12 weeks.

Despite advances in therapy, bleeding and thromboembolic events are frequent complications in patients with left ventricular assist device (LVAD) support. Maintaining warfarin in therapeutic range has been shown to be more challenging in this patient population compared to other indications. Patients with LVADs on warfarin typically are within goal international normalized ratio (INR) range 36-57% of the time, compared to about 65% for other indications. The goal of this study was to evaluate if an INR remote monitoring system along with the implementation of a standardized warfarin management protocol improves warfarin time in therapeutic range (TTR) for patients with LVADs. This single-center, retrospective, observational study included 78 patients with LVADs that were followed at our academic center from January 2015 to October 2017. In October 2016, we updated our warfarin management protocol and implemented a remote monitoring system with patients' weekly INR results monitored. The primary objective of the study was to determine the difference between TTRs in remote monitoring versus standard monitoring. We found that the average TTR was significantly higher in the remote monitoring group compared to the standard monitoring cohort (61.1% vs. 40.0%, p < 0.005). However, bleeding, thrombotic incidence, and hospital readmission rates were similar between the two patient cohorts. Remote monitoring improved warfarin TTR significantly in this study and may have the potential to improve anticoagulation-related outcomes in patients with LVADs.

Background Increased inflammation has been well defined in coronavirus disease 2019 (COVID-19), while definitive pathways driving severe forms of this disease remain uncertain. Neutrophils are known to contribute to immunopathology in infections, inflammatory diseases, and acute respiratory distress syndrome, a primary cause of morbidity and mortality in COVID-19. Changes in neutrophil function in COVID-19 may give insight into disease pathogenesis and identify therapeutic targets. Methods Blood was obtained serially from critically ill COVID-19 patients for 11 days. Neutrophil extracellular trap formation (NETosis), oxidative burst, phagocytosis, and cytokine levels were assessed. Lung tissue was obtained immediately postmortem for immunostaining. PubMed searches for neutrophils, lung, and COVID-19 yielded 10 peer-reviewed research articles in English. Results Elevations in neutrophil-associated cytokines interleukin 8 (IL-8) and interleukin 6, and general inflammatory cytokines IFN-inducible protien-19, granulocyte macrophage colony-stimulating factor (GM-CSF), interleukin 1β, interleukin 10, and tumor necrosis factor, were identified both at first measurement and across hospitalization (P Conclusions Literature to date demonstrates compelling evidence of increased neutrophils in the circulation and lungs of COVID-19 patients. Importantly, neutrophil quantity and activation correlates with severity of disease. Similarly, our data show that circulating neutrophils in COVID-19 exhibit an activated phenotype with enhanced NETosis and oxidative burst.

Background At the University of California, San Diego, routine coronary angiography has generally been performed in men 40 years of age and older and women 45 years of age and older before pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (CTEPH). The prevalence of significant coronary artery disease (CAD) in this population has not been evaluated, however, and the optimal screening strategy has not been established. This study sought to evaluate whether the current approach may be better optimized on the basis of cardiac risk factors. Methods This study included 462 consecutive patients with CTEPH who were undergoing preoperative coronary angiography for pulmonary thromboendarterectomy. Baseline demographic and medical information was recorded. Major cardiac risk factors included: diabetes, hypertension, hyperlipidemia, body mass index 25 kg/m2 or greater, tobacco use, and family history of CAD. Charts were then reviewed for presence of significant CAD and revascularization. Results Significant CAD was found in 13.4% of patients who underwent routine preoperative coronary angiography; it was present in only 5% of patients younger than 50 years of age, compared with 16% of patients 50 years old and older. No patient younger than 50 years of age without cardiac risk factors was found to have significant CAD. Furthermore, in patients younger than 50 years of age, significant CAD was found only among those with 3 or more major risk factors. Conclusions In patients younger than 50 years of age with CTEPH, the prevalence of significant CAD was low. Omitting preoperative coronary angiography in this subset of patients is reasonable when no coronary risk factors are present. Preoperative coronary angiography is warranted in individuals 50 years of age and older, as well as in those younger than 50 years who have significant risk factors for CAD.

BACKGROUND Computed tomography (CT) has an established role in detecting perforation of implanted pacemaker and defibrillator leads. The clinical significance of incidental finding of delayed lead perforation remains unclear. The aim of this study was to assess the prevalence of lead perforation as detected by CT in a cohort of patients undergoing transvenous laser lead extraction and characterize the association between finding of incidental lead perforation with periprocedural outcomes. METHODS Consecutive patients that underwent chest CT and lead extraction were retrospectively assessed for presence of lead perforation. A total of 143 patients and 348 leads were assessed. The finding of lead perforation was correlated with findings from peri-procedural transesophageal echocardiography (TEE) and outcomes of the lead extraction procedure. RESULTS Lead perforations (including perforations

BACKGROUND: Outcomes following hepatitis C virus (HCV)-viremic heart transplantation into HCV-negative recipients with HCV treatment are good. We assessed cost-effectiveness between cohorts of transplant recipients willing and unwilling to receive HCV-viremic hearts. METHODS: Markov model simulating long-term outcomes among HCV-negative patients on the transplant waitlist. We compared costs (2018 US$) and health outcomes (quality-adjusted life-years, QALYs) between cohorts willing to accept any heart and those only willing to accept HCV-negative hearts. We assumed 4.9% HCV-viremic donor prevalence. Patients receiving HCV-viremic hearts were treated, assuming $39,600/treatment with 95% cure. Incremental cost-effectiveness ratios (ICERs) were compared to a $100,000/QALY gained willingness-to-pay threshold. Sensitivity analyses included stratification by blood type or region, and potential negative consequences of receipt of HCV-viremic hearts. RESULTS: Compared to accepting only HCV-negative hearts, accepting any heart gained 0.14 life-years and 0.11 QALYs, while increasing costs by $9,418/patient. Accepting any heart was cost-effective (ICER $85,602/QALY gained). Results were robust to all transplant regions and blood types, except type AB. Accepting any heart remained cost-effective provided post-transplant mortality and costs among those receiving HCV-viremic hearts was not >7% higher compared to HCV-negative hearts. CONCLUSIONS: Willingness to accept HCV-viremic hearts for transplantation into HCV-negative recipients is cost-effective and improves clinical outcomes.

Surgically accessible lesions of chronic thromboembolic pulmonary hypertension (CTEPH) are classified as proximal or distal based on the distribution of thrombus burden in the pulmonary vasculature post operatively. Surgically accessible distal CTEPH lesions typically has a higher risk profile and worse clinical outcomes in less experienced centers, but the underlying molecular differences between proximal and distal CTEPH lesions remain unknown. Oxylipins, a diverse group of bioactive lipid mediators, have previously been implicated in a range of disorders including pulmonary hypertension. Therefore, we sought to characterize oxylipin profiles among patients with proximal and distal operable CTEPH lesions, as well as those with idiopathic pulmonary arterial hypertension (IPAH). We studied 271 patients with proximal operable CTEPH (n=123), distal operable CTEPH (n=74), or IPAH (n=74). Liquid chromatography-mass spectrometry was used to analyze oxylipin profiles in each patient. We found that patients with distal operable CTEPH had elevated levels of proinflammatory oxylipins while those with proximal CTEPH had an increase in procoagulant oxylipins. Notably, the proinflammatory oxylipins elevated in distal operable CTEPH were similarly elevated in IPAH. These findings suggest that distal operable and proximal CTEPH represent heterogenous disease processes. Furthermore, oxylipin profiles may be useful for potential risk stratification and therapeutic targeting in CTEPH.

A sex paradox is seen in pulmonary arterial hypertension (PAH) whereby female sex is a risk factor for development of the disease but male sex is often associated with poorer outcomes. Although data are limited regarding the potential molecular mechanisms underlying sex-specific variations in PAH including its various subtypes, there is emerging evidence regarding the potential role of sex differences in pathways governing the balance between underlying inflammatory and vasoactive mechanisms. Chronic thromboembolic pulmonary hypertension (CTEPH) is a subtype of pulmonary hypertension that is classically characterized as a procoagulant state and yet also involving some degree of proinflammatory activity. Therefore, we sought to determine whether eicosanoid mediators, endogenous lipid signaling molecules that have been implicated in a range of inflammatory and vasoactive responses, vary by sex in patients with CTEPH. We studied 287 patients (43.5% female) with confirmed CTEPH from a single center and assayed plasma samples using liquid chromatography – mass spectrometry to profile 500 eicosanoid analytes. We found significant sex-specific variations in eicosanoid profiles after adjusting for age and BMI, with males demonstrating a predominance of inflammatory-pathway related eicosanoids. Sex-specific variation in eicosanoid pathway related mechanisms may underlie sexual dimorphism in CTEPH outcomes.

With the advent of direct-acting antiviral agents, there has been a rapid rise in hepatitis C virus-infected (HCV+) heart transplantation. We aimed to understand local and regional differences in utilization and allocation of HCV+ hearts. Using United Network for Organ Sharing (UNOS) de-identified data from January 1, 2016 to September 30, 2019 we compared trends in the utilization rates (hearts transplanted/donors recovered) of HCV-uninfected (HCV-) to those of HCV+ nonviremic (HCV-NV) and viremic (HCV-V) hearts nationally and by UNOS region. We also evaluated allocation rates (hearts successfully allocated/donors recovered) by organ procurement organization (OPO). We found that (1) in 2019, national utilization rates for HCV-NV and HCV-V hearts were the same as HCV- hearts (27.6% for HCV-NV, 30.9 for HCV-V, and 31.7% for HCV-, P = .277); (2) utilization rates of HCV-NV hearts were low in regions 3 and 4 and of HCV-V hearts in regions 3, 4, and 8 even in the contemporary period since 2018; and (3) there was marked variability in allocation of HCV+ hearts at the OPO level even within the same UNOS region. We conclude that despite national strides in the utilization of HCV+ hearts for transplantation, more aggressive allocation of HCV+ hearts at the OPO level may still significantly affect the organ shortage.

Background: Transvenous lead extraction of cardiovascular implantable electronic device (CIED) has been proven safe in the general patient population with the advances in extraction techniques. Octogenarians present a unique challenge given their comorbidities and the perceived increase in morbidity and mortality. Objective: To assess the safety and outcomes of CIED extraction in octogenarians to younger patients. Methods: We performed an extensive literature search and systematic review of studies that compared CIED extraction in octogenarians versus non-octogenarians. We separately assessed the rate of complete procedure success, clinical success, procedural mortality, major and minor complications. Risk ratio (RR) 95% confidence intervals were measured using the Mantel-Haenszel method. The random effects model was used due to heterogeneity across study cohorts. Results: Seven studies with a total of 4,182 patients were included. There was no difference between octogenarians and non-octogenarians in complete procedure success (RR 1.01, 95% CI 1.00 – 1.02, p = 0.19) and clinical success (RR 1.01, 95% CI 1.00 – 1.01, p = 0.13). There was also no difference in procedural mortality (RR 1.43, 95% CI 0.46 – 4.39, p = 0.54), major complication (RR 1.40, 95% CI 0.68 – 2.88, p = 0.36), and minor complication (RR 1.43, 95% CI 0.90 – 2.29, p = 0.13). Conclusion: In this study, there was no evidence to suggest a difference in procedural success and complication rates between octogenarians and younger patients. Transvenous lead extraction can be performed safely and effectively in the elderly population.

Heart transplantation remains the gold standard of therapy for patients with end-stage heart failure. Submassive pulmonary embolism in a patient with heart failure is generally considered a contraindication to immediate heart transplantation, given the risk of right heart failure posttransplant. Generally patients must wait for extended periods of time to recover from pulmonary embolism therapies before being listed for transplant. We report a case of successful concomitant pulmonary thromboendarterectomy and heart transplantation.

Inflammatory pseudotumor (IPT), also known as plasma cell granuloma, is a rare lesion of unknown etiology that occurs in many organs, especially in the lung. Here we report five cases of IPT arising in pulmonary artery mimicking chronic thromboembolic disease, not previously documented in the literature. Those cases were identified at our institute among over 2500 pulmonary endarterectomy (PEA) specimens acquired from 2000 to 2017. The cohort included three men and two women with a median age of 41 years (range: 23-54). All patients presented with dyspnea and radiologic findings of pulmonary artery thromboembolism, some concerning for intimal sarcoma. The duration between disease onset and PEA ranged from 6 months to approximately 3 years. Histologically, all cases showed proliferation of spindle cells with marked inflammatory infiltrates composed predominantly of plasma cells, histiocytes, and small lymphocytes. Ancillary studies were performed in each case and ruled out other possibilities, such as sarcoma, lymphoma, plasmacytoma, IgG4-related disease, and infection. IPT arising in pulmonary artery presenting clinically as acute or chronic thromboembolic disease is very unusual, in which clinical data, radiographic findings, and histopathologic features have to be integrated for reaching the proper diagnosis.

Background: Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare and progressive subtype of severe pulmonary hypertension. Premature ventricular contractions (PVC) are common and can be a marker of cardiomyopathy. We aimed to describe the incidence, location and predictors of PVCs in CTEPH patients undergoing Pulmonary Thromboendarterectomy surgery (PTE). Hypothesis: PVCs are common in CTEPH patients and the right ventricle would be the most common location of PVCs. Methods: We reviewed the charts of 883 consecutive patients who were referred for PTE. 12-lead ECGs were reviewed for presence of PVC. Demographics, baseline lab and imaging were extracted from chart review. Predictors of PVCs were analyzed using multivariate backward logistic regression. PVC location was identified using standard location algorithms based on the 12-lead ECG. Results: Overall, 6.5% (n=57) of patients had PVCs. Surprisingly, the majority of PVCs originated from the left ventricle (75.4%, N=43). The most common location was non-outflow tracts with LV non-outflow tract (59.3%, N=34), followed by RV non-out tract (19.3%, N=11). Within the non-outflow tract region, the majority of the PVC location appeared to be septal related (moderator band, posterior fascicle or posterior medial papillary muscle). The mitral annulus was also a common location (15.8%, N=9). In a multivariate model, heart failure (OR 2.8, p= Conclusions: PVCs are not uncommon in CTEPH patients undergoing PTE surgery. Overall, 6.5% of patients had PVCs with the majority originating in the left ventricle (75.4%). Using standard ECG criteria, the most common location was the LV non-outflow tract. Heart failure, CAD, sleep apnea and obesity increased the odds of having a PVC.

Introduction: Measures of frailty are predictive of morbidity and mortality in patients with left ventricular assist device (LVAD) placement. While Fried’s Frailty Assessment (FFA) is well-validated, sarcopenia has emerged as a powerful predictor. The additive value of sarcopenia to existing frailty assessments and its association with outcomes in patients undergoing LVAD implantation is not well-characterized. Hypothesis: We assessed the hypothesis that sarcopenia in addition to FFA improves the assessment of frailty and that patients identified as frail may experience worse outcomes after LVAD implantation. Methods: We evaluated 34 patients who underwent LVAD implantation at our medical center between January 2018 and December 2020. Perioperative FFA score ≥ 3 was defined as frail. Skeletal muscle indices were measured using perioperative computed tomography imaging of the psoas and pectoralis major and minor muscles areas. Sarcopenia was defined per the lowest skeletal muscle tertile with total psoas area index ≤4.45 and pectoralis muscle index ≤4.50. Results: Of the 34 patients who had LVAD placement, 12 received HeartWare HVAD and 22 received HeartMate III. Five patients met criteria for frailty based on FFA. When combined with frailty based on sarcopenia, 13 additional patients met criteria. There were no differences in age (57 vs 54.5 years, p = 0.49) or gender (89% vs 100% male, p = 0.62) between the frail and non-frail groups. On Kaplan-Meier analysis, the frail group had significantly higher rates of composite outcome of 30-day readmission and all-cause mortality (log-rank p = 0.027), (Figure 1). There was no difference in rates of transplantation. Conclusions: In conclusion, FFA is a commonly used tool for assessing frailty in patients with heart failure. The addition of sarcopenia assessment allows for higher sensitivity in identifying patients with frailty who are at risk for poor outcomes. Larger studies are needed to validate these findings.

Background: Pulmonary Thromboendarterectomy (PTE) is a specialized cardiac surgery for treating chronic thromboembolic pulmonary hypertension (CTEPH). Sinus node dysfunction is seen in this population as patients often require epicardial pacing after cardiac surgeries. We aimed to define the incidence, predictors, and outcomes of sinus node dysfunction after PTE surgery. Hypothesis: We hypothesized that sinus node dysfunction requiring epicardial pacing is common after PTE surgery. Methods: We reviewed the charts of 883 consecutive patients who were referred to University of California San Diego for PTE. Demographics, lab results and imaging were extracted from chart review. Predictors and outcomes were analyzed using multivariate backward logistic regression model or independent samples T test respectively. Results: Overall, 60% (n=533) of patients required epicardial pacing for an average of 3.9 +/- 2.2 days. Strongest predictors of epicardial pacing were coronary artery disease (OR 2.6, p= Conclusions: The majority of patients undergoing PTE for chronic thromboembolic pulmonary hypertension develop sinus node dysfunction requiring temporary epicardial pacing. The mechanism of sinus node dysfunction appears transient as the average pacing requirement is 3.9 +/- 2.2 days, and ultimately only 1% (n=4) require permanent pacemaker placement. Patients who required epicardial pacing had significantly longer post-operative length of stay and ventilator days.

PURPOSE: Ventricular arrhythmias (VAs) are common in patients after left ventricular assist device (LVAD)n implant and are associated with worse outcomes. However, the prevalence and impact of VA in patients with durable biventricular assist device (BIVAD) is unknown. We performed a retrospective cohort study of patients with BIVADs to evaluate the prevalence of VA and their clinical outcomes. METHODS: Consecutive patients who received a BIVAD between June 2014 to July 2017 at our medical center were included. The prevalence of VA, defined as sustained ventricular tachycardia or fibrillation requiring defibrillation or ICD therapy, was compared between BIVAD patients and a propensity-matched population of patients with LVAD from our center. The occurrence of adverse clinical events was compared between BIVAD patients with and without VA. RESULTS: Of the 13 patients with BIVADs, 6 patients (46%) experienced clinically significant VA, similar to a propensity-matched LVAD population (38%, p = 1.00). There were no differences in baseline characteristics between the two cohorts, except patients in the non-VA group had worse hemodynamics (mitral regurgitation and right-sided indices), less history of VA and were younger. BIVAD patients with VA had a higher incidence of major bleeding (MR 3.05 (1.07 – 8.66), p = 0.036) and worse composite outcomes (log-rank test, p = 0.046). The presence of VA was associated with worse outcomes in both LVAD and BIVAD groups. CONCLUSION: Ventricular arrhythmias are common in patients with BIVADs and are associated with worse outcomes. Future work should assess whether therapies such as ablation improve the outcome of BIVAD patients with VA.

Objectives The aim of this study was to assess if pre-procedural computed tomography (CT) could identify high-risk operative features and predict increased procedural complexity. Background Unpredictable lead adhesions can make lead extraction complicated. Adhesions are known to affect leads with longer indwelling time but can unpredictably affect newer leads. Methods Consecutive patients who had CTs performed ≤90 days before their planned lead extraction (LE) were included. CTs were reviewed blinded to outcome according to a preset checklist. The outcome was a combined endpoint of procedural complexity and major complications. Results Between January 1, 2015 and July 1, 2018, 143 patients underwent CT and LE. Median age was 68 years (interquartile range [IQR]: 54.4 to 76.5), and 35% were female. Median age of extracted leads was 111 months, and 126 (43%) were >10 years. CT detected lead perforation ≥5 mm (n = 13), 1 cm (n = 102), lead fracture (n = 8), and severe ipsilateral venous stenosis/occlusion (n = 36). The procedure was complex in 63 cases. There were 2 deaths, and 6 major complications. Patients with severe lead adhesions had more complex procedures (n = 36 vs 29; p = 0.04), whereas none of the other findings on CT were significantly associated with worse outcome. In patients with leads that had an indwelling time Conclusions Pre-procedural CT can be used to locate severe lead adhesions in patients planned for lead extraction. In patients with indwelling leads

To assess the efficacy of ramelteon in preventing delirium, an acute neuropsychiatric condition associated with increased morbidity and mortality, in the perioperative, ICU setting.Parallel-arm, randomized, double-blinded, placebo-controlled trial.Academic medical center in La Jolla, California.Patients greater than or equal to 18 years undergoing elective pulmonary thromboendarterectomy.Ramelteon 8 mg or matching placebo starting the night prior to surgery and for a maximum of six nights while in the ICU.Incident delirium was measured twice daily using the Confusion Assessment Method-ICU. The safety outcome was coma-free days assessed by the Richmond Agitation-Sedation Scale. One-hundred twenty participants were enrolled and analysis completed in 117. Delirium occurred in 22 of 58 patients allocated to placebo versus 19 of 59 allocated to ramelteon (relative risk, 0.8; 95% CI, 0.5-1.4; p = 0.516). Delirium duration, as assessed by the number of delirium-free days was also similar in both groups (placebo median 2 d [interquartile range, 2-3 d] vs ramelteon 3 d [2-5 d]; p = 0.181). Coma-free days was also similar between groups (placebo median 2 d [interquartile range, 1-3 d] vs ramelteon 3 d [2-4 d]; p = 0.210). We found no difference in ICU length of stay (median 4 d [interquartile range, 3-5 d] vs 4 d [3-6 d]; p = 0.349), or in-hospital mortality (four vs three deaths; relative risk ratio, 0.7; 95% CI, 0.2-3.2; p = 0.717), all placebo versus ramelteon, respectively.Ramelteon 8 mg did not prevent postoperative delirium in patients admitted for elective cardiac surgery.

This study sought to prospectively evaluate the prevalence, risk factors, and short-term major clinical outcomes of mobile thrombus detected on transvenous leads in patients undergoing lead extraction.The prevalence and clinical significance of thrombus on transvenous leads in patients undergoing lead extraction is not well characterized.Consecutive patients undergoing transvenous lead extraction for noninfectious indications were enrolled. Preoperative transesophageal echocardiograms were performed prospectively for all patients to examine for mobile thrombus. Anticoagulation was not started for thrombus unless other indications were present. Clinical endpoints of mortality and cardiovascular morbidity (symptomatic pulmonary embolism, myocardial infarction, or cerebrovascular accident) were assessed at a minimum of 2-month follow-up.A total of 108 patients underwent lead extraction for noninfectious indications. Lead thrombi were detected in 20 (18.5%) patients and all were

The management of heparin-induced thrombocytopenia (HIT) in the perioperative period for patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest (DHCA) can be a challenging clinical scenario. Once a diagnosis of HIT has been established, heparin products typically are avoided and alternative therapies for anticoagulation are started. Alternative anticoagulation strategies for CPB are limited and often have various pharmacokinetic profiles that may lead to increased perioperative bleeding. Historically the use of a GPIIb/IIIa inhibitor, such as tirofiban, followed by unfractionated heparin (UFH) is the typical alternative for surgeries requiring DHCA in patients with HIT at the authors' institution. This article presents a case in which cangrelor followed by UFH was used in a 20-year-old patient with suspected HIT and chronic thromboembolic pulmonary hypertension undergoing pulmonary thromboendarterectomy surgery requiring CPB and DHCA. Due to the frequency of significant postoperative bleeding encountered when using tirofiban and UFH, it was decided to attempt to block platelet aggregation with significantly shorter-acting cangrelor. The authors hypothesized that cangrelor would reduce the risk of significant bleeding compared with tirofiban because of its favorable pharmacokinetics. Specifically, cangrelor has a short elimination half-life of 3 to 6 minutes, and its elimination is not altered by renal and hepatic impairment. This case report discusses the pathophysiology of HIT, the alternative anticoagulants used for HIT type II in pulmonary thromboendarterectomy, and the potential of cangrelor in conjunction with UFH to be a favorable option for patients in similar clinical scenarios.

The HeartWare centrifugal-flow ventricular assist device system (HVAD) is a viable option for treatment of advanced heart failure. There is a growing trend toward the use of less invasive techniques in cardiac surgery, and the thoracotomy technique for HVAD implantation may provide benefits not available with conventional approaches.The LATERAL trial is a multicenter, prospective, non-randomized, single-arm trial that utilized data from 144 patients enrolled in the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) database at 26 centers in the United States and Canada. The primary composite end-point was success at 180 days defined as alive on the originally implanted device and free from disabling stroke (modified Rankin Scale score3), transplanted or explanted for recovery. The key secondary end-point was mean length of initial hospital stay.The primary end-point was successfully achieved in 88.1% of patients and was significantly greater than the pre-defined performance goal of 77.5% set from historical sternotomy data (p = 0.0012). The key secondary end-point-mean length of initial hospital stay -was 18 days and was significantly shorter than the pre-defined performance goal of 26.1 days obtained from historical sternotomy data (p0.0001). The adverse event profile further demonstrated the safety of the thoracotomy approach. The overall patient survival was good, and bleeding requiring reoperation was significantly less frequent than that observed in previous studies using the sternotomy approach.This prospective clinical trial provides validation that implantation of the HVAD system via the thoracotomy approach used in the LATERAL study represents a safe and effective alternative to median sternotomy in selected patients intended for a bridge-to-transplant indication.

BACKGROUND AND OBJECTIVES Atrial arrhythmias (AAs) are common after cardiac surgeries including pulmonary thromboendarterectomy (PTE). This study was done to identify patients at highest risk of developing post-PTE AA and their length of stay (LOS). METHODS We reviewed 521 consecutive patients referred to University of California San Diego (UCSD) for PTE and examined their demographics as well as their baseline pulmonary hemodynamics to determine risk factors for AA. RESULTS Overall, 24.2% of patients developed an AA after PTE. Patients who developed AA had a significantly longer Intensive Care Unit (ICU) LOS (median: 5 vs 3 days, P

AIMS Chronic pain at the cardiovascular implantable electronic device (CIED) generator or lead insertion site that is not otherwise manageable carries a IIA indication for extraction. However, limited data exist evaluating causes of pain and outcomes of extraction in eliminating pain. A multi-centre retrospective observational study was conducted to evaluate outcomes of patients undergoing device extraction for treatment of chronic device pain. METHODS AND RESULTS Twenty-seven out of 2188 lead extraction candidates (1.3%) met the chronic pain IIA indication for extraction [50 ± 16 years; 14 (51%) women]. Onset, severity, triggers, and pain management were measured before and after extraction. Device type, procedure done (with/without reimplantation), and positive tissue cultures were noted. Pain was reported as constant (n = 14; 50%), intermittent (n = 13; 46%), and movement-triggered (n = 14; 50%). Average severity of pain was seven out of 10 (10 being the worst). Post-extraction, 18 (66%) received freedom from pain, including all patients with poorly formed pockets (n = 2) and subclinical infections (n = 2). Of the 18, 11 underwent reimplantation (61%) without recurrent pain. Nine still had pain (44 ± 17 years; seven women) after extraction. Eight of the nine underwent reimplantation, three on the contralateral chest wall and five ipsilaterally. Pain severity decreased (n = 5), increased (n = 1), or was unchanged (n = 3). CONCLUSION Chronic pain at the CIED generator site can present as chronic or movement-triggered pain, and can be due to subclinical infection or a poorly formed device pocket. Extraction relieved constant and intermittent pain in two-thirds of patients. Extraction appears less successful in eliminating pain in women who undergo subsequent reimplantation.

Pulmonary thromboendarterectomy (PTE) remains the treatment of choice for patients with operable chronic thromboembolic pulmonary hypertension (CTEPH). It is a technically demanding operation that offers patients with CTEPH improvements in survival and quality of life. In this article, we describe the operative technique of PTE in detail.

As organ procurement organizations nationwide see an increased opportunity to retransplant already transplanted hearts, we would like to share the overview and process of our 2 successful cases. Heart retransplantation increased our cardiac placement rates by 2.64% and 2% in 2015 and 2019, respectively. Spread across a nation that sees over 3500 heart placements annually, a 2% increase would be substantial. Since 2009, our cases stand as the only documented heart retransplantations in the United States. However, United Network for Organ Sharing data shows that potential exists. From a facilitation perspective, we have developed a protocol to ease the matching process. From a surgical perspective, these cases had no complications and saved 2 lives, with each heart now beating in a third person. We hope that by sharing our process and success, we can familiarize fellow organ procurement organizations and transplant communities with this viable opportunity.

Chronic thromboembolic pulmonary hypertension is optimally treated by pulmonary thromboendarterectomy (PEA). Treatment effectiveness has been evaluated principally using single-center series. Data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database were used to evaluate a volume-outcomes relationship for PEA.Circulatory arrest procedures performed between 2012 and 2018 were identified through a Society of Thoracic Surgeons Adult Cardiac Surgery Database Participant User File. For descriptive purposes, total center procedural volume categories were computed: low (0-75th percentile,16); medium (76-95th percentile, 16-100); high (95th percentile,100). Mixed effect modeling was used to evaluate the effect of center procedural volume (modeled continuously) on operative mortality, adjusting for preoperative risk factors, with centers as a random effect.There were 1358 cases performed across 64 centers (low volume: n = 49 of 172; medium volume: n = 12 of 527; high volume: n = 3 of 659), with 42 centers performing less than 10 operations during the period. Procedural volume increased 2.6-fold between 2012 and 2018 (94 vs 339), with 79% of the change in volume accounted for by 4 centers. The median preoperative pulmonary artery systolic value was 74 (interquartile range, 57-88) mm Hg, with no difference (P = .55) by center volume categories. In unadjusted analysis, patients at high-volume centers required fewer transfusions, had shorter ventilator and intensive care unit duration, had a lower frequency of postoperative extracorporeal membrane oxygenation, and trended toward lower mortality (2.1% vs 5.2%; P = .051). Operative mortality was lower at higher-volume centers (adjusted odds ratio [1-case increase], 0.997; 95% confidence interval, 0.994-1.0; P = .025).Most PEA procedures are performed among a small number of centers, with high-volume hospitals having favorable outcomes. These data suggest a potential role for PEA regionalization.

BackgroundIncreased inflammation is a hallmark of COVID-19, with pulmonary and systemic inflammation identified in multiple cohorts of patients. Definitive cellular and molecular pathways driving severe forms of this disease remain uncertain. Neutrophils, the most numerous leukocytes in blood circulation, can contribute to immunopathology in infections, inflammatory diseases and acute respiratory distress syndrome (ARDS), a primary cause of morbidity and mortality in COVID-19. Changes in multiple neutrophil functions and circulating cytokine levels over time during COVID-19 may help define disease severity and guide care and decision making.MethodsBlood was obtained serially from critically ill COVID-19 patients for 11 days. Neutrophil oxidative burst, neutrophil extracellular trap formation (NETosis), phagocytosis and cytokine levels were assessed ex vivo. Lung tissue was obtained immediately post-mortem for immunostaining.ResultsElevations in neutrophil-associated cytokines IL-8 and IL-6, and general inflammatory cytokines IP-10, GM-CSF, IL-1b, IL-10 and TNF, were identified in COVID-19 plasma both at the first measurement and at multiple timepoints across hospitalization (p < 0.0001). Neutrophils had exaggerated oxidative burst (p < 0.0001), NETosis (p < 0.0001) and phagocytosis (p < 0.0001) relative to controls. Increased NETosis correlated with both leukocytosis and neutrophilia. Neutrophils and NETs were identified within airways and alveoli in the lung parenchyma of 40% of SARS-CoV-2 infected lungs. While elevations in IL-8 and ANC correlated to COVID-19 disease severity, plasma IL-8 levels alone correlated with death.ConclusionsCirculating neutrophils in COVID-19 exhibit an activated phenotype with increased oxidative burst, NETosis and phagocytosis. Readily accessible and dynamic, plasma IL-8 and circulating neutrophil function may be potential COVID-19 disease biomarkers.